Monday Morning MD: Aaron Rodgers and the truth about ACLs

The Packers superstar made news with his comments about his 2004 anterior cruciate ligament (ACL) surgery. One of the NFL’s best and most athletic quarterbacks attributed some of his success to his cadaver donor being a “fast SOB” as he shaved almost 3/10ths of a second off his 40-yard dash time after surgery.
Known to have a unique sense of humor that even fools teammates, Rodgers comments were surely made tongue-in-cheek. It wouldn’t be the first time a player was kidding the media as Danny Trevathan joked about having someone else’s kneecap last year. In any case, Rodger’s quotes give us a good chance to separate the realities from the myths of ACL surgery.
Was Rodgers’ cadaver donor a “fast SOB”?
There would be no clear way for Rodgers to know whom the donor was. The only cadaver information typically available to the surgeon is the age, sex, cause of death and dimensions of the graft. Upon expiration, donors are screened for diseases before being deemed viable for tissue harvesting. There is no direct tissue typing or matching to the recipient. Details of the donor’s life, ethnicity, occupation or athleticism are not considered or available. In fact, Rodgers ACL graft donor could have been female.
Could someone else’s ACL make you faster post surgery?
No way the graft itself makes anyone faster. First, the actual ACL from a cadaver is never directly harvested for use due to size and geometry limitations. Commonly, the patellar tendon (with two attached bone blocks), Achilles tendon (with bone on one side) or all soft tissue grafts (like posterior tibialis tendon) are used. Second, the ACL functionally can’t make one faster. It serves to stabilize the femur to the tibia and thus actually could be said to “slow’ the knee down to prevent shifting.
Is it feasible to decrease one’s 40-yard dash time after ACL surgery?
Rodgers said he was a 4.95 (40-yard dash) guy and then ran 4.66 after ACL surgery. Yes, ACL rehab can make someone faster/quicker if the athlete was not performing maximally prior to injury. A fully trained athlete can’t be made faster; however, a sub-optimally functioning player can be helped. In fact it is possible for an uninjured player to go thru ACL rehab style training and have performance improve. I personally witnessed Philip Rivers become a better athlete after ACL surgery in 2008. I wish I could take credit for his increased speed/mobility but it was a result of his hard work with top Chargers athletic trainers. Rodgers is downplaying his own dedication to rehab post-surgery here.
How is it possible to play football for multiple years without an ACL?
Playing through an ACL tear is possible in certain circumstances. Rodgers played high school, junior college and into his time at Cal with a torn ACL. Rivers played in the 2008 AFC Championship Game six days after arthroscopic surgery with a torn ACL.
The ACL is like an internal seat belt for the knee. Just like it is possible to drive a car with the seat belt broken, one can function without the ACL. However, when racing NASCAR, your seat belt better be working, just like your ACL is needed for the aggressive running/jumping/cutting of football. Without an ACL it is playing “Russian roulette” with your knee as there can be permanent cartilage damage if the knee gives out.. Rodgers was able to play through with a brace at lower levels of competition. Rightfully, his ACL surgery was done before exiting college and advancing to the NFL.
Is cadaver the best ACL graft like Rodgers recommends?
Certainly, the cadaver ACL worked for Rodgers. However, that would not be my (or most NFL physicians’) first recommendation. Fortunately, disease transmission risk with cadaver grafts is small. Even so, autograft (own tissue) patellar tendon with bone on each end is the most popular graft choice in the NFL. Bone-tendon-bone (BTB) graft is the strongest and most likely to succeed. Cadaver can work but has the higher re-tear rate over hamstring and BTB autografts. Using cadaver leads to less post-operative soreness and makes for a quicker recovery but may not be worth the significant (up to 30% per the ACL Study Group) re-tear rate. The cadaver failure rates are highest for younger and more active patients. Remember, missing a second consecutive season likely means the end of an athlete’s career.
Why is cadaver a potentially weaker graft choice?
All ACL grafts are scaffolds for one’s own tissue to grow into. Logic would tell you that your own tissue grows best into your own tissue versus someone else’s. A graft that does not incorporate and ligamentize is doomed to failure. There is no true rejection, as that is an immunologic response and cadaver patients don’t need to take special medications like organ transplant patients. Perhaps when technology arrives to tissue type and match to donor to recipient, cadaver failure rates will improve.
Can the ACL be stronger after surgery?
After one year of recovery, my patients are twice as likely to tear the other knee ACL versus re-tearing the reconstructed ACL. This is why I recommend bracing during the first year with early return to sport. The new ACL is not truly stronger, just lower re-tear risk. No, I would not recommend prophylactic ACL surgery.
Has ACL recovery gotten faster?
It sure seems that way. Rehab techniques have improved but there is no way to speed up biology. The media with Adrian Peterson’s nine-month return to rush for 2000 yards makes it seem like early return is something new but ACL recovery has been getting faster for over a decade. Shannon McMillian returned to play international soccer 102 days after her ACL surgery and at four months played in the 2003 Women’s World Cup for USA.
What is best thing to do for an ACL tear?
Pick a surgeon you trust and not the specific technique or graft choice. There are many ACL techniques (open, double incision, single incision, medial portal technique, all-inside) and many autograft (BTB, hamstring, quad tendon, contralateral) or allograft (BTB, Achilles, posterior tib) options. Let the chef tell you what he cooks well and the best meal to order. Let the surgeon tell you the procedure he is most comfortable with and what is best for you. Don’t make a surgeon who recommends cadaver harvest a hamstring graft. In other words, when you go to Morton’s get the steak. If you want fish, go to Oceanaire. Trust the recommendation or choose a different restaurant or surgeon.
Overall the joke is on us to take Rodgers comments so literally. It is very nice of Rodgers to thank and credit his ACL donor. At least this gave us a chance to discuss some of the fact and fiction about ACL surgery and recovery.

Monday Morning MD: Giving out pain medicine "like candy"

Calvin Johnson created a stir with his in-depth interview this week. The recently retired Detroit Lions wide receiver spoke candidly about a wide range of topics. At one point the likely future hall of famer compared giving out pain meds to handing out candy.
The way Johnson’s interview was promoted, it seemed like the nine-year veteran was going to slam the NFL and the Lions medical staff. In reality, after watching the interview in its entirety, I don’t feel that is the case at all and agree with a majority of what Megatron said. Let’s analyze the top five highlight quotes.
“Team doctors and trainers were giving them (pain medications) out like candy.”
If Johnson was referring to the accessibility of pain medication, where players could obtain pain medication thru the team doctors, that is indeed true. NFL players do not have to go to the local retail pharmacy like the rest of the world. However, that hardly means that pain medication wasn’t controlled and medically indicated.
No formal prescriptions are written, because scripts are only needed if one is to the pharmacy. That doesn’t mean there wasn’t appropriate documentation and control. Doctors manually record each pill administered or dispensed. Team physicians chart or dictate every encounter to document medical examinations and use of medications. Players use to make fun of me for “talking to myself” into my dictaphone on game day.
Most people are not aware that each medication, narcotic or otherwise, is tracked. Teams have a mandatory quarterly drug audit where every pill is accounted for. When news of the painkiller lawsuits came out, several players jokingly asked me how come I never “hooked them up” and why pain pills were not more plentiful to them.
Johnson acknowledges that medication availability became more difficult in the later half of his career. Toradol for prophylactic use was discouraged and team doctors were no longer allowed to travel with any narcotic medication for road games. It was typical for a team athletic trainer to walk up and down an airplane aisle after a road game to pass out Advil or Tylenol, which can be considered painkillers.
“The team doctor, the team trainers, they work for the team”
This is certainly true. Keep in mind, team doctors only work for the NFL as a side job. They all have university or private practices and only a minor portion of their income is related to the team. To think that physicians would jeopardize their personal careers by knowingly mistreating players defies logic.
Johnson added “and I love ’em, you know”. “They’re some good people, you know. They want to see you do good.” I agree that a medical staff wants to return a player to the field and that goal is in alignment with players’ desires to stay in the line up.
“You can’t take Toradol and pain medicine every day”
I certainly agree with this statement. During my 17-year tenure as team physician, we never used medication on a daily basis or to get thru a practice. Toradol, a strong anti-inflammatory with pain relieving properties which is in the same category as Advil, was used sparingly. Ketorolac, the generic name, is typically limited to 20 doses over a five-day period. Players received no more than 20 doses across an entire season. Our club even performed a Toradol study that showed it was safe to be used this way and presented it at the NFL Physicians Society meetings.
On game days there may have been a line for Toradol, but players just didn’t jump into line. The use of medication was predetermined and consented. No one was forced or encouraged to take Toradol or pain pills to play. In fact, players were the ones asking for the medications. We rarely used Vicodin or other narcotics as we felt that might interfere with the mental aspects of football.
“Concussions happen”
There is no question that concussions are unavoidable in football. Johnson didn’t come out and blame the league for knowingly putting players at risk, but he described a culture that demands that players play. There is no question the culture has changed but it is far from perfect as the Case Keenum situations still occur.
Megatron missed only nine games in nine seasons and was listed on the injury reports for his ankle, knee, Achilles, shoulder, thumb, quadriceps, groin, thigh, hand, foot and back. Interestingly, Johnson was never listed for head injury, although he acknowledged he had his “fair share” of concussions. Note the second half of Johnson’s career was played with a spotter in the sky, sideline video injury review and independent neurotrauma specialists on the sideline.
“Catching the ball hurt”
I don’t doubt that Megatron played thru pain. He described getting his knee drained 12 times during one season. I have witnessed the everyday pain he spoke about.
There is no question that catching a pass with his deformed finger with a boutonniere injury would be painful. He waited until retirement to have surgery, as the long recovery would have cost him game time.
Fortunately, Johnson made over $100 million in his career, another few million wouldn’t change his life and he chose health. It does seem he had some gas left in the tank and there were other factors. He hinted at the Lions lack of winning. “If we would have been a contender, it would have been hard to let go. If the Lions could get out of their own way…”
Johnson has the most receiving yards and touchdowns for any player to never win a playoff game. His 2008 team was the only team ever to go 0-16.
For the most part, I agree with what Johnson said and I hope he makes the Hall of Fame. He harbored no grudges, made no accusations, nor pointed any fingers. There was honest dialogue from his point of view. This type of frank discussion from a players perspective only helps football and helps fans understand the game behind the scenes. Thanks for letting me share some of my reaction to his comments.

Monday Morning MD: Ready or not?

With just under a month to go before training camp, much attention is paid to whether an injured player will be ready to go. Typically, this is the time of year for optimism. Players, coaches and management signal mostly confidence of good recoveries. Players are not going to doubt themselves and “coach speak” abounds.
Joe Flacco declared himself ready for training camp and his coach said he was “ahead of schedule” coming off his ACL tear. Tony Romo (clavicle, Mumford) has been full go at practice. Jordy Nelson (ACL) is reportedly raring to go. Jamaal Charles is on pace for another quick ACL comeback. Pete Carroll expects Jimmy Graham and Thomas Rawls to be ready. Arian Foster (Achilles) is purportedly ready for camp. Even top-five rookie pick Jalen Ramsey who had recent knee surgery says he is 100% for camp. Despite this optimism, often teams will start a player on PUP, if even for a day, to provide insurance for a set back.
When optimism is not rampant, it leads one to worry. The news has not been universally positive for Le’Veon Bell. First, he injured two ligaments (PCL and MCL) which makes recovery harder than if he had an isolated ACL tear. Bell hopes to be able to cut by training camp. He is not sure his knee is fine right now. It’s possible Bell will be just fine this coming season, but we are not hearing the usual early optimism.
Hopefully, Bell can overcome this lack of usual optimism. For now, the Steelers have not extended his rookie contract which expires later this year.
MMMD 1: Happy and safe Fourth of July
Last year’s Independence Day news was dominated by the injury to Jason Pierre-Paul. This year, JPP has a public service announcement cautioning fireworks safety. He shows the significant damage to his hand (CAUTION: Graphic picture attached to link) during the PSA. Unfortunately, most of the 10 things to know about JPP fireworks injury that I wrote last July came true. Fortunately, he is still playing football as expected.
Buccaneers cornerback C. J. Wilson also injured his hand with fireworks last year. He unfortunately retired from the NFL as a result of his injuries.
Hopefully, history will not repeat itself this July 4th.
MMMD 2: Players and guns
I don’t know what the statistics are for men average age 25 and gun violence but it just seems like three recent incidents seem like too many.
Aqib Talib was shot (or shot himself) in Dallas where details are still sketchy. Thankfully, he avoided major nerve, artery or structural injury. A Buccaneers rookie was shot up to three times. Ex-Colts Zurlon Tipton is tragically dead at age 26 from an accidental self-inflicted gunshot wound. He also had a December 2015 gun incident.
With gun control a national topic, I don’t know what the answer is. It just seems to me enough players are injured during football that these gun related injuries seem senseless.
MMMD 3: Players worth the pay?
This week there was plenty of discussion if players were worth the extravagant pay. The bottom line is that some owner was willing to pay it, so that is the value. After all, the value of an oceanfront home is what someone is willing to pay for it.
Before people hate on players for their high salaries, consider that top athletes make a fraction of what top Wall Street executives make. In addition, NFL salaries are not guaranteed for injury and corporate executives have much longer careers.
MMMD 4: Al Jazeera HGH investigation
Even though the main informant has recanted, the NFL plans to interview all players implicated by the report. I have no idea if Peyton Manning did or didn’t use HGH, but I do know that HGH would not have helped his nerve issues as some have claimed. If and when players are exonerated, I hope that generates the same publicity as the accusations have.
MMMD 5: “Billionaire A–hole”
Jake Plummer ripped the NFL’s marijuana stance and Jerry Jones for saying it was “absurd” to say there is a link between football and CTE. It may be ridiculous for Jones to say there is no CTE link, but it is also unproven for Plummer to say marijuana prevents brain damage. While it may be true that marijuana by-products may ease head injury symptoms, that is a long way from proof of preventing brain damage from concussions. Seems to me the owners and players need to listen to scientists and conduct more studies. Otherwise, it is just more concussion politics.
MMMD 6: New medical lawsuit
Just when we thought the health and safety litigation was finally ending with the concussion settlement and the dismissal of the painkiller lawsuit, now comes more litigation. The painkiller lawsuit has been reformatted into 32 individual cases against the team as opposed the league in general.
If this legal challenge goes to court, I am sure the teams will claim that they do not practice medicine and that pain medicine decisions were made by the medical staff. I find it interesting that no individual team physician has been named over this issue yet.
MMMD 7: ProFootballDoc scorecard
Last week I showed a picture of Jaylon Smith continued use of an ankle foor orthosis (AFO) and how that means his peroneal nerve really has not improved. Ed Werder has now confirmed that there was no significant improvement in the injured nerve so far. As I first indicated before the Combine, Smith is unlikely to play in 2016. The question is now becoming if he will make 2017. I hope he can beat the odds.
This makes the current 2016 record 10-0 from the previous 9-0.

Monday Morning MD: Video is the history

Lesson number one in medical school is history is the most important part of a physical examination. Before touching the patient a detailed history is required. History for a traumatic injury is a description of the mechanism. What better description is there than actual video of the injury? Every day, I have at least one patient that shows me how they were hurt by showing me team, cellphone or GoPro video.
This is the basis of my video injury analysis which was honed with 17 years of Monday morning visits to the video department to reverse engineer injuries I saw and examined from the day before.
When I ran onto the field to tend to a player, my assistant physicians were trained to watch the video board for replays to see the mechanism of injury. Late in my career, sideline injury video was introduced for concussion but found to be more helpful for other injuries as it is difficult to judge head injuries by video.
The English Premiere League has now introduced video to the field. Liverpool medical staff now have the injured player on the pitch in front of them, yet still rely on video. This further validates my use of video to assess injuries. ipaddr
Of course, I would be more accurate examining a player than just looking at video. Although I am flattered by some who say I never miss, that is hardly the case. During the 2015 season, I publicly documented 94.3% accuracy. Ten times my video assessment was not accurate, but it was correct on 165 occasions. Some injuries had inadequate visual evidence and I could not opine at all.
When Jaylon Smith injured his knee on New Year’s Day, I tweeted my immediate worry about nerve injury. Later, video Smith posted of himself walking confirmed the peroneal nerve injury despite the player’s denials. In the offseason there is limited video so I rely on other methods of deduction. A recent photo had Smith still with an ankle foot orthosis (AFO), indicating his nerve is still not functional. ClfYaxdWYAAJWRM
I am not diagnosing players on twitter. If I had any role in treatment or access to X-rays or MRIs, I would not be able to comment due to HIPAA privacy laws. I deal in insider knowledge, not insider information. I know the vast majority of medical personnel in the NFL but I never contact them for information, nor would they violate player’s privacy and tell me.
When I am treating or have treated a player, I skip commenting specifically. For example, I did not comment on Drew Brees’ shoulder issue last year. On occasions when a team physician colleague discusses an injury with me, I no longer voice a public opinion. I also examined some players in preparation for the Combine and of course I did not comment on their collegiate injuries since I had the insider information. When I do speak about a player that I have treated, I have permission from the athlete or limit my discussion to publicly available knowledge.
There is no substitute for an examination, but there is growing use of video on the field to help with diagnosis. The use of video in injury assessments is here to stay.
MMMD 1: “Wide receiver” fracture revisited
With all the prominent pass catchers who have suffered a Jones fifth metatarsal fracture, I proposed to rename the injury. Bears WR Marquess Wilson re-broke his foot and was announced to likely start on PUP.
A second surgery is needed up to 20% of the time as has happened to Dez Bryant and Julian Edelman recently. Bryant has been recently cleared as his second procedure was in January. Edelman’s timeline is tight as his second screw insertion was reported in May. Sammy Watkins had April first-time surgery and may not be ready until the first game.
Remember, this fracture happens due to a “watershed area” in the bone where there is limited blood supply. This fact also makes healing more tricky.
MMMD 2: ACL mental hurdle
Anterior cruciate ligament reconstruction presents physical and mental hurdles. I wrote about this in my MMMD extra: ACL surgery series weekly during the 2014 offseason as I chronicled what the recovery for Von Miller and Rob Gronkowski might be like.
Joe Flacco’s admits his biggest remaining hurdle is mental. Until a player gets hit on the knee and momentarily thinks he re-tore the ACL, but gets up to realize his knee is ok, he will always have doubt.
Despite many early returns to sport, the mental hurdle to feel the knee is 100% as well as the biology of ACL graft incorporation makes the second year back the better year. The scary thought is that Todd Gurley should be even better this season.
MMMD 3: Doctors held to higher standard than lawyers
Johnny Manziel’s attorney mistakenly texted an AP reporter violating attorney/client privilege. If a medical professional breached doctor/patient confidentiality, there would be stiff potential penalties. Even if the medical information was leaked accidentally and inadvertently, there are HIPAA penalties up to 50k per single occurrence. Although just as damaging to Manziel, there are no such fines for a legal transgression of this type like there would be for medical leaks of information. In both cases the aggrieved party can take their own legal action, but only medical has built-in penalties.
MMMD 4: Offseason program over, injuries still coming
Players and coaches are essentially off for a month before training camp begins. The medical work continues as well as the injury announcements. This year just under half of teams lost a significant player to injury this offseason. Add Saints CB Kyle Wilson to the list who has been placed on Injured Reserve with a shoulder labral injury.
MMMD 5: Cautionary tale for stem cells
All stem cell treatment is not the same. Most stem cell treatments are illegal in the United States due to safety concerns. Unregulated stem cell treatments can have disastrous consequences including developing tumors in your body.
Only one’s own un-manipulated stem cells are legal in the US. Any other form is either not truly stem cells or is being performed illegally. There are some legitimate cutting edge clinics outside the US, but many more are dangerous shams than the real deal.
MMMD 6: Be true to yourself
One of the lucky things from my almost two decades in the NFL is to have met many great people and worked for many great coaches. What I learned is that one needs to be true to one’s self to be successful. I worked under hard line leaders and nice guy players’ coaches. Both styles work if you are real, as players will see thru any false pretenses.
Mike Riley was a genuinely nice guy and the players loved him for it. Riley recently made news when he met up with a rape victim who harbored hatred for the coach and instead became a “friend and ally” by genuinely caring.
Riley is just a really good human being. Being genuine and true to yourself is the key. Hip hip hooray! (Those who have played for Riley will know what I am referring to.)
MMMD 7: ProFootballDoc scorecard
When Calvin Johnson posted gruesome pictures of finger surgery, speculation arose of his potentially coming out of retirement. I wrote last week that having the procedure meant the absolute end of Megatron’s football career. Contrary to the thoughts, that type of finger surgery is only done when a player retires due to the long recovery. Johnson indeed has now emphatically confirmed that he is not coming back.
The previous 2016 record of 8-0 now increases to 9-0. I will continue to publicly keep track of right and wrong analysis this entire season.

Monday Morning MD: Female firsts

There have been a series of female firsts in the NFL this past year. First a woman was named an official, then the first training camp coach, followed by full-time coach. Now a woman is head team physician for the first time.
Sarah Thomas was named the first female official last season and she performed well. Jen Welter was hired by the Cardinals as the first female coach when Bruce Arians appointed her to coach inside linebackers during the preseason. The Bills then made history by hiring Kathryn Smith as the first female full-time coach as Rex Ryan made her a special teams quality control coach.
Now the Redskins have hired Dr. Robin West as the NFL’s first female head team physician. She certainly deserves the position as I know her as a top quality orthopedist from her time as an assistant team physician for the Steelers.
It comes as no surprise that women can do any of these NFL jobs. Amy Trask was the CEO of the Raiders for 16 years.  The Ravens have had Dr. Leigh Ann Curl as their lead orthopedist for over a decade. I know both to be well respected across the league circles.
To me, the hiring of Dr. West is really a non-story, as women have held prominent places in medicine forever. The bigger sign of changing times in the NFL is not that a female was named to be a head team physician but that there was a news conference to make the announcement.
Back when I was named head team physician, there wasn’t even an announcement despite being the youngest ever and younger than some players. Recently, it became common for teams to issue a press release to announce physician staff changes. A press conference is unprecedented and a sign of things to come with the increasing roles of team physicians. In my 17 years in the NFL, I am glad I never had to hold a press conference.
Times are a changing in many ways for the NFL. Congrats to all the female trailblazers.
MMMD 1: #1 priority of minicamp
I wrote a month ago how the main priority was to get out of the offseason healthy. Typically, 50% of teams lose a significant player by end of minicamp.
The Chargers ended minicamp practice early and even skipped the final day after and injury scare to Danny Woodhead. An ankle injury to the third down specialist in 2014 sent the previously playoff bound Bolts into a tailspin. Fortunately, injury was avoided, but the team also ended practice early.
This follows the trend where the Jaguars changed their practice regimen this year after losing their first-round pick Dante Fowler, Jr. to an ACL tear last offseason. Expect the offseason safety trend to continue next year.
MMMD 2: New “Injury” described
After almost two decades as a NFL team physician, I thought I had seen every injury imaginable. This week, I learned about a new “injury”.
The Bills held Karlos Williams out of minicamp practice because he was overweight. The Buffalo RB self-described it as an “injury of pregnancy” where he gained sympathetic weight with his expectant fiancée.
Just when I thought I had seen it all…
MMMD 3: Every club has a team dentist
The Redskins announced Josh Doctson missed practice to get a tooth pulled.  It is common to have dental issues and players get quick access.
Players get top medical care and that includes dentistry. Every team has a team dentist that will take part in physicals with a dental check station. Also players don’t wait weeks to get in to see the dentist. The appointments are usually streamlined by a call from the team athletic trainer and often planned to not miss practice time.
MMMD 4: Maurkice Pouncey had seven surgeries
When the Steelers center was first injured, I knew he would need surgery and his season was in jeopardy. What I didn’t know is that Pouncey’s ankle would become infected and that he would require seven surgeries and a skin graft.
Infections are nasty and can happen with any surgery as in this case when the wound does not heal properly. This revelation explains why Mike Tomlin was mum about Pouncey’s potential return during last season and why the Steelers wasted their only IR/dfr designation on Pouncey,
MMMD 5: Concussion politics continue
Two weeks ago, I wrote about the significant politics of concussions. This week, competing concussion researchers were at it again.
Boston University was to present its highest public health award to the primary subject of the Concussion movie. Instead the award was rescinded and the former honoree claimed there was a “vendetta”.
I don’t know who is right or wrong (or if both are wrong) in this situation, but this is another example of unbecoming behavior for researchers and universities. Certainly it would have been interesting to see the university of one competing concussion research group honor a hated competitor. However, once the honor was set to be bestowed, I am not sure what forces come to play to make a university change its mind. I also don’t know why the researcher would claim a “vendetta” against him. Last time I checked, it was a privilege, not a right, to receive an award.
The bottom line is that in science, researchers collaborate and share information. This is true unless you are talking about concussion researchers and that needs to change. It is about finding a solution and not claiming credit or assigning blame.
MMMD 6: 10 person practice squad renewed
Practice squads are traditionally fixed at eight players. Two years ago the NFL and NFLPA agreed to a two-year experiment to expand to 10. That has expired but word comes that new rule has been extended. This certainly makes sense as the NFL no longer has a developmental league with NFL Europe’s demise.
MMMD 7: Dolphins bullying scandal fallout
Almost three years later, three of the four major figures in “bullygate” are still out of the NFL. The target, Jonathan Martin, has retired from the NFL. The two fired Miami staffers have not found jobs in the league. The main accused bully, Richie Incognito, missed 2014 but has been with the Bills since 2015.
Offensive line coach Jim Turner has not found another NFL job and is with Texas A&M. Head athletic trainer Kevin O’Neil was made a scapegoat and despite being called “the best I ever worked with” by Jimmy Johnson, could not land another job until now. Only this week, O’Neil has found a job as athletic trainer at Florida International University.
Congrats and I hope he can put the false accusations behind him as there is always more to the story.

Monday Morning MD: Lightning strikes again

Baltimore 2015 first-round draft pick Breshad Perriman never played a down in his rookie season. History is likely to repeat itself as the Ravens wide receiver may miss his sophomore campaign as well. Perriman reportedly “partially” tore his ACL in offseason workouts on Thursday.
Medically, partial ACL tears are rare. The knee is either stable or it is not. The term “partial” is overused when it comes to describing ACL injury. The vast majority of time, a partial tear leads to the same ACL reconstruction surgery as a “complete” tear.
MRIs often properly call it a partial tear because typically the injury is not seen on all images but that doesn’t mean the ACL is not completely torn. Imagine if a rope frays and breaks, there are still normal looking portions of the rope but the rope no longer holds. In the same way, a MRI can show normal parts of an ACL, yet it is not in continuity. This is why I say a good orthopedic exam can be more accurate than imaging.
The other reason teams use the term “partial ACL” is to give hope until the diagnosis of full tear is confirmed by second opinion. This is the same reason why teams say “MRI pending” when the team typically knows before the MRI that the ACL is torn. The same optimism was applied last season when the team remained hopeful of a Perriman return after in-season PCL surgery and stem cells, where I was more realistic.
Perriman’s second opinion is coming today. I hope he beats the odds and it is found that his ACL is not completely torn. Apparently the wide receiver did finish practice after the non-contact injury before reporting with swelling the following day. This also favors an isolated tear without associated cartilage injury. His main chance is to hope the finding is a spurious MRI diagnosis and that his knee is stable. Unfortunately, I think that possibility is less than 5%, as in my 17 years as an NFL team physician I’ve never encountered a true partial ACL tear.
The likelihood is that Perriman will need formal ACL reconstruction which would mean missing his second straight season. Sometimes compensation plays a role but there is no direct indication that there is any relationship to his PCL injury on his other knee.
Raven’s fans can keep hope that last season Kiko Alonso returned to play for the Eagles with a partial ACL tear; however, he was largely ineffective. It would be great news and a big surprise if Perriman’s second season was not unfortunately over now.
MMMD 1: Offseason injuries piling up
I previously indicated that approximately half of NFL teams will suffer a significant/season-ending injury before OTAs and minicamps are done. Add three ACL tears to the list of teams already suffering injury. Besides Perriman, Saints pass-rusher Hau’oli Kikaha (3rd time) and Patriots TE Michael Williams both tore ACLs. We are shy of 50% of teams losing players (and I hope it stays that way) but with another week and many minicamps to go, it seems inevitable that history will repeat itself.
MMMD 2: Jamaal Charles ready for minicamp?
Reports surfaced that the Chiefs running back might participate in minicamp. When Charles tore his ACL eight months ago, I wrote how I expected a good comeback for 2016 despite his age. As well as he is doing, I sincerely doubt that Charles will be a minicamp participant.
Things may be progressing smoothly, but there needs to be full medical clearance before participation in any practice. This is not to say Charles won’t be doing drills on the side.
Charles made a great comeback last time from ACL surgery to have a career high 1500 yards rushing but was overshadowed by Adrian Peterson’s 2000 yards. He will be back for 2016, just not yet.
MMMD 3: Megatron not coming back
Calvin Johnson posted gruesome pictures of his finger surgery. Some speculated that perhaps fixing his finger which may have interfered with his ability to catch passes signaled a potential comeback.
I think it indicates just the opposite and that Johnson will remain retired. In my experience, such extensive surgery and long recovery for a boutonniere finger correction is only done at the end of one’s career. To me, having the finger surgery ends any speculation about thoughts of returning to play.
MMMD 4: Jalen Ramsey video
Many Jaguars fans were overjoyed to see their top-five pick running after knee surgery. The video indicates good progress but he is still a long way from returning. Just look at how he limps when slowing down and one can see he is not ready to cut or change directions yet. Ramsey will be ready for training camp, but he is not there yet.
MMMD 5: Oakland safety incidents
In this health and safety era, one major reason for the Raiders needing a new place to play is injury concerns. Oakland is the only NFL city remaining that shares the field with a Major League Baseball club. Early season home games are played on a partial dirt field and this leads to additional injures.
This weekend on SiriusXM NFL radio, I heard first-time host Brian Costello tell a story about Antonio Cromartie breaking ribs and having to be carted in a circuitous route outside the stadium through heckling fans to get to medical attention. I can corroborate that dangerous situation as it happened to me as I cared for NFL players as well. The locker room is up two flights of stairs from the field and the x-ray room is up an additional three flights of stairs and down a long corridor. Not to mention the locker rooms are so small that there is inadequate treatment areas where it forces players to be taped, examined and treated in the hallways and shower areas.
MMMD 6: Real Football Network
I am pleased to announce that I am joining Real Football Network. The number one SiriusXMNFL duo of Pat Kirwan and Jim Miller leads the effort to provide insider video and audio for the serious football fanatic or fantasy player. I will provide similar in-depth medical analysis as I have here, but in video and audio form.
MMMD 7: ProFootballDoc scorecard
I wrote last week that Broncos knew about Aqib Talib’s injury immediately, even while details of the shooting were sketchy. Although the Broncos CB was lucky the bullet avoided major nerves and arteries, there is still muscle damage and he will indeed miss the rest of the offseason program.
Will count this group of assessments into one correct tally for 2016. This improves the previous 7-0 record to 8-0.

Monday Morning MD: Stop with the concussion politics

Everyone needs to stop taking sides and protecting their own interests. The NFL, team owners, Congress, NIH, concussion researchers, movie makers, medicine in general, players, coaches and media are all at fault here. Controversy was re-ignited and politics further injected recently when a congressional report criticized the NFL and their doctors. The goal should be to prevent concussions and find a cure for chronic traumatic encephalopathy (CTE), not playing politics of the blame/credit game.
The NFL is wrong to play politics and deny funding for a $16 million Boston University study that was selected on merit by the National Institute of Health (NIH). Obviously the league has not yet learned from its past mistakes and being slow to react to the concussion issue.
Team owners are wrong for continuing to shoot from the hip and deny links to CTE. Jerry Jones calls it “absurd” and Jim Irsay compares the risk of football to that of taking aspirin.
Congress is wrong for making it a Democratic committee issue. CTE is not a partisan disease. What impartiality does a report have that harshly criticizes and singles out a “NFL doctor” when it never attempted to reach out to or speak to that physician before publishing findings?
The National Institute of Health (NIH) is wrong to allow the NFL to call their $30 million grant unrestricted with “no strings attached”. In reality, the league retained “veto power”. The prestigious NIH should have never allowed itself to be manipulated that way or accept conditional monies.
Concussion researchers are wrong for taking sides by becoming paid experts in concussion litigation. The different camps are wrong in pressuring families to donate to one group over another and for not sharing the brain tissue to verify findings.
Movie makers are wrong for perpetuating the lies of the self-serving claims of one man that he discovered CTE. The reality is the degenerative brain disorder was first described in the 1920’s. I do applaud the awareness the Concussion movie brought to the issue but the truth would have done the same trick.
The medical community in general is wrong for being slow to provide definitive care for head injury. Diagnosis is inexact and there is no proven medication or treatment. There is even disagreement on cognitive rest versus controlled brain stimulation after concussion.
Players are wrong for not taking care of their own. In the much publicized Case Keenum incident, watching the film shows two of his offensive lineman clearly see their QB stagger and fall down as they try to help him up, yet neither directs him to the sideline or calls for medical attention.
Coaches are wrong for downplaying concussions as mild or blaming the media. The “back when I played” philosophy just doesn’t work.
Media is wrong for feeding the hysteria. Labeling members of the Head, Neck and Spine Committee as “NFL” doctors is an exaggeration. They should always point out most are tenured professors at prestigious universities that receive no pay from the league for their committee service. Also the media mantra of “a concussion is a concussion” is a disservice as medicine will indeed categorize severity and type one day.
We need answers, not politics or self-serving stances. Let’s all work to a concussion solution and not worry about who gets the blame or the credit.
MMMD 1: CTE happens outside of football
This is not a political item. This is stating fact about an issue that is very personal to me. BMX legend Dave Mirra died four months ago and has been independently diagnosed by multiple centers to have CTE, the first action sports athlete to have the confirmed diagnosis.
Clearly CTE is a societal problem that extends beyond football. It is an issue that affects me deeply as Dave is the fourth former professional athlete friend to have committed suicide. I attended and spoke at his celebration of life and hope to never have to do that again for anyone else.
MMMD 2: Aqib Talib shot
While details are still sketchy about the circumstances of the Dallas nightclub shooting, the medical information is clear that the Broncos cornerback will make a full recovery. The gunshot wound did not damage any major arteries (presumably no nerves) or ligaments. However, it was significant enough to warrant an overnight stay at the hospital but no surgery was required. Do not expect Talib to participate in minicamp or the rest of the offseason program, but he should be good to go for the start of training camp.
How do clubs get their medical information so quickly when it is not even known how he was shot? The team medical staff is usually asked to get involved early and speak to treating physicians. During my 17-year Charger career, I was asked to immediately intervene and obtain medical information on two shootings of players, Terrence Kiel and Steve Foley. This is just one of many circumstances where the team physician’s job is not what the public thinks it is.
MMMD 3: First round rookie injury ups and downs
Jalen Ramsey received double good news. His meniscus tear did not require a repair with longer recovery and was not related to his previous reported microfracture surgery.
Josh Doctson has an Achilles issue and minor foot injury and will be held out of practice for now. Hopefully this is all precautionary for the Redskins.
Technically, Dante Fowler, Jr. (ACL), Kevin White (tibial stress fracture) and Breshad Perriman (PCL) are not rookies but all three missed their inaugural season. These three first round “rookies” are all on track to make a strong 2016 debut.
MMMD 4: Offseason injury survival
All 32 teams have injuries already. In my experience, half of teams will have a significant loss that affects the season. This offseason is not proving to be any different.
Titans OL Byron Bell (ankle fracture/dislocation), Lions TE Tim Wright (ACL), Ravens CB Jumal Rolle (Achilles) and Jaguars DE Jonathon Woodward (Achilles) are among the few that are out for the season. Bengals TE Tyler Eifert (ankle), Bills DE Shaq Lawson (shoulder) and Cowboys DT Maliek Collins (fifth metatarsal) and among the many that have had surgery that could effect the upcoming season.
Despite the current CBA with limited offseason work, the injuries will continue to pile up this summer.
MMMD 5: Happy National Cancer Survivor Day
Certainly Eric Berry and his family celebrated the occasion this Sunday. The Chiefs safety beat Hodgkin’s lymphoma and has returned to play football.
Another less famous NFL player, David Quessenberry, has not been so lucky yet. The Texans offensive tackle has battled non-Hodgkin’s lymphoma since 2014. He was declared in remission last year and had regained the 30 pounds he lost. This week he was placed on the non-football injury list (NFI) and will not play this season. He missed the last two season to cancer and now will miss a third. If he returns, it would be unprecedented, as he will have missed four NFL seasons (first one due to ankle injury). The bigger hope is the NFI status doesn’t mean there is recurrence of cancer.
MMMD 6: Stolen laptop is a big deal
We are not talking team espionage here. This is not Spygate, but it is a much bigger deal. The theft of a Redskins athletic trainer’s laptop occurred during Combine medical rechecks. This surely meant that the medical records of over 300 potential draft picks were exposed. Also potentially at risk were previous Combine and team medical records as well as potentially thousands of NFL players as the league has moved to electronic medical records.
The good news is that there is no indication that any medical records were accessed. The bad news is the laptop was password protected but not encrypted as required by federal HIPAA law. The Redskins could face significant fines and punishment. There is also a requirement to notify all players whose records were potentially compromised.
I am sure the league has circulated a memo reminding all clubs that encryption is mandatory to avoid the risk of hefty federal fines.
MMMD 7: ProFootballDoc scorecard
When news of Jalen Ramsey’s meniscus tear broke, I surmised that the procedure would be a simple menisectomy (trimming) and not a repair that affects his coming season. This opinion was not based on video (as there was none), but simply my orthopedic and NFL team physician background of knowing common injury patterns. Fortunately for the Jaguars, the simpler arthroscopic surgery will have Ramsey back well before training camp. The better long-term news is the meniscus tear was in a different area of the knee than the previous high school surgery, meaning there shouldn’t be recurring problems.
This takes the previous 2016 6-0 record to 7-0.

Monday Morning MD: When your examination room is the 50-yardline

I have faithfully written a weekly column (plus other features) without a break since October 14, 2013 when I started my post team physician media adventure. After a total of 153 thousand-plus word articles, I am taking my first break this Memorial Day weekend. Last week at the Marshall Faulk charity fundraiser, I ran into the author of this Physician Magazine piece written 15 years ago who has graciously allowed me to reprint it. The feature was unusual as the Chargers allowed unprecedented game day access in a time that was well before the first HBO Hard Knocks. I hope you enjoy it.

When Your Examination Room Is the 50-Yardline

Every professional sports franchise has them—team doctors. In this special Physician report, we follow an NFL team doctor on Game Day.
by Mike Yorkey
December 15, 2001: 12:07 p.m.
It’s two hours before kickoff against the Oakland Raiders, and San Diego Chargers’ All-Pro linebacker Junior Seau is all over Dr. David Chao.
“Hey, everybody, a reporter is here to do a story on Chao!” hollers out an animated Seau, who’s obviously enjoying seeing the tables turned for a change. “Doc’s going to be famous. C’mon and see this everybody!”
I’ve just arrived in Dr. Chao’s cubbyhole office, which adjoins the Charger training room and locker room underneath the west grandstands of Qualcomm Stadium. In this quiet, windowless environment, it’s difficult to believe that the Chargers and Raiders will square off in a noisy nationally televised game two hours from now.
Several half-dressed players—some of the biggest human beings I’ve ever seen up close—pop in their heads to see what the commotion is all about. Meanwhile, Junior continues to tease Dr. Chao. “This is what you gotta write,” he says. “You gotta tell everyone that he’s the best doctor in the whole wide world! You don’t have enough paper to print everything I’m going to tell you about him.”
I shoot a glance toward Dr. Chao, whose grinning smile is a mixture of pride and embarrassment. “Now, Junior . . .”
“Take a look at my fingers and hands,” says Junior, as he fans out his massive, battle-scarred extremities. I peer at his supersized fingers, which resemble long, gnarled tree branches. The digit and middle fingers on the left hand make several intriguing zigzags, but what’s especially interesting is the double-sized knuckle on the middle finger. How did that happen? Junior, however, wants to show off Dr. Chao’s handiwork on his right hand.
“See this scar?” he says, pointing to a nasty gash below the padded thumb area. “Chao was trying to write my initial, so gave me this S.”
Junior is right. I have never seen a set of simple interrupted sutures come out in the shape of an S, but that is how his brutish scar healed. “I got sewn up during a game, but it doesn’t matter,” says Junior, as he turns serious for the first time. “Chao is a good man. He’s done a lot for the kids in my foundation,” he says.
As a native San Diegan, I am well aware of Junior’s foundation and his remarkable story. The son of American Samoa immigrants, Junior grew up in nearby Oceanside, where he made good on the gridiron and starred at USC. He was a first-round pick of the Chargers in 1990, and when riches and glory came his way for becoming one of the best linebackers in NFL football, he formed the Seau Foundation, a non-profit charitable organization.
“How does Dr. Chao help?” I ask Junior.
“Let’s say a kid on the Oceanside High football team goes down with a serious knee injury and comes to us for help,” replies Junior. “The boy doesn’t have medical insurance. We cover the cost of the surgery bay and materials, which are given to us at cost, while Chao donates his surgical skills. I would say that Doc’s done ten kids for me,” says Junior. “He’s a good man.”
Dr. Chao is still smiling like a Cheshire cat.
12:45 p.m.
For the last ten minutes, I’ve been playing straight man to Dr. Jerry Hizon, a Charger team doctor who must have moonlighted at the Comedy Store during residency.
“You know where David went to high school?”
“No, I’m afraid not,” I reply.
“Think 90210.”
“You mean Beverly Hills High?”
“You got it. And did you know that David thought Harvard was too easy?”
“He went to Harvard?”
“Sure, but you probably want to write about David’s water polo days at Northwestern. He was All Big-10 while he was in med school.”
I look at Dr. Chao, and he’s rolling his eyes again. Now, I’m really confused, which causes Dr. Hizon and the rest of the doctors in the room to crack up. I feel like I’m part of a freshman hazing.
Welcome to the sports medicine world of NFL football, a fraternity that David Chao has belonged to since 1997, when he joined the Chargers. The 37-year doctor is affiliated with Oasis Sports Medical Group, the official team physicians for the Chargers. As the lead doctor, David is on-call 24/7 throughout the season, which lasts six to seven months. He also flies with the team on all road trips, which often start with a Friday morning flight to points east and doesn’t end until the team plane returns to San Diego on Sunday evening. During the week, David maintains his practice with Oasis, seeing patients, performing surgery (usually knee, shoulder, and hip repair) and making “house calls” at the Chargers’ practice facility near Qualcomm Stadium.
For today’s game against the Raiders, David is quarterbacking the medical coverage. Dr. Hizon, a family practitioner, and another Oasis doctor, Dr. Paul Murphy, an orthopedist, will assist him. This trio works all games, home and away. Dr. Bob Speer, a pediatric anesthesiologist, Dr. Calvin Wong, a family practitioner, and Dr. Stan Sherman, a trauma anesthesiologist, will handle back-up roles. Finally, an orthopedic fellow, Dr. Chris Pallia, is on hand to observe the action. With seven doctors on the field, you could say that the Chargers are ready for anything, but experience has been a stern teacher in the violent world of NFL football.
We are ninety minutes before game time. A dozen players drop by David’s office to have their sore joints and muscles checked—ankles, knees, hips, ribs and shoulders. Many are linemen and all are gargantuan: the typical size appears to 6-foot, 5-inches tall and 300 pounds. These players will be slamming their bodies in the trenches with devastating impacts. When an irresistible force meets an immovable object, something has to give, and it’s usually a joint, a bone or a ligament.
“The guys are big and the size is good, but I think what you have in the NFL is the last of the warriors,” says David. “Injuries are a big part of the game, however. Out of 53 guys on the team, I would say that I operate on 15 to 20 during and after the season, and I’ve operated on more than half the players on this team at one time or another.” No wonder why Dr. Hizon told me that the NFL stands for the Not For Long league. The players have incredibly short careers.
The talk turns to what Dr. Chao does during the game. “What’s it like running out on the field with a capacity crowd and all those people on TV watching you treat a player for an injury?” I ask.
“What I’ve found about sports medicine is that you have to keep a little perspective,” says David. “I’m here as a doctor and a physician, and my job is to see the players, and that’s it. The fans are here to see the players play, not the doctors. If I’m not noticed in a game, then I’m happy. In fact, I’m the only guy on Sunday that team owner Dean Spanos wants to do nothing. My goal is to stay out of the way and in the background.”
“But don’t you have to make quick judgment calls?” I ask.
“The easiest part about sports medicine is the medicine itself, if that’s where you keep your focus. I remember when I was working at the X Games in San Francisco. There was a doctor who was helping me, and we had a freestyle motocross rider go down with a lunate dislocation. I evaluated and treated him, and then I sent him off with another X Games doctor to the hospital with instructions to get X-rays and call me back with the results. About an hour later, I received a call on my cell phone from the other doctor, and he said, `It’s a non-displaced radial fracture. I’m going to put him in a cast and bring him back.’ ”
“I asked whether he was sure, and he said yes, but I asked him to bring me a copy of the X-rays when he returned. When I got a look at them, he said that it’s the only fracture, the radial head, but I immediately noticed that his lunate was dislocated. It’s a common error to make, but an error that I am 100 percent sure that he would not have made if he was back in his own office. With everything else going on at the X Games, his focus was off, which was a reminder to me to take care of the medicine first.”
2:07 p.m.
We run out onto the field with the Charger players, and the wall-to-wall noise of the capacity crowd creates intense energy. Everywhere I look, everyone has his game face on. We are minutes away from kickoff against the first-place Raiders, the evil-dreaded Silver and Black who have been the Chargers’ bitterest rivals for forty years. This late-season matchup has drawn the third-largest home crowd in franchise history—67,349—and filled Qualcomm Stadium to the brim. Unfortunately for the Chargers, two-thirds of the fans appear to wearing black Raider jerseys.
David stands amongst the coaches and players on the Charger sideline. As soon as the opening kicking sails through the air, he doesn’t take his eye off the action. He must concentrate on the players because a career-ending—or life-threatening—injury is just a snap of the ball away. It’s also not a good idea to direct your gaze away from the action if you value keeping your body in one piece.
“I’ve covered high school, junior college and college football, but NFL games are different,” says David. “At the high school level, if there is a pitch coming toward me, I will wait until the players are right on top before stepping back. In the college game, I start to think about moving when I see a sweep coming my way. But NFL `game speed’ is so fast that if quarterback Doug Flutie even looks my way, I’m backing up because they are coming hard. As you see on TV, the players will fly 10, 12 yards out of bounds sometimes. They are on top of you in a split-second because their speed and quickness are so unbelievable.”
2:25 p.m.
Injured player!
The game is only a few minutes old when the Chargers’ rookie cornerback Davis Sanchez is slumped on the grass, writhing in pain. David and team trainers James Collins and Scott Trulock sprint out to midfield, where they take several minutes tending to the young player. After they gingerly assist him to his feet, Sanchez nearly collapses from back spasms. They half-carry him to an examination table behind the bench for a further look, but Sanchez is grimacing with each step. He looks done for the day.
Before the game, David told me that decisions about whether an injured player can return to the game are made as a team. James Collins, as the head trainer, is the first to make an evaluation. If it’s an orthopedic question—a tender back, an injured knee, or a deranged shoulder—then Dr. Chao takes the lead. If it’s a possible concussion or something internal, then Dr. Hizon is the go-to guy.
Earlier in the season, quarterback Doug Flutie was knocked silly in a game against the Kansas City Chiefs. Dr. Hizon proceeded to ask him several standard memory questions:

  • “What’s the date?”
  • “Who are we playing?”
  • “What’s the score?”
  • “Who did we play last week?”

When Flutie didn’t have the answers, he was through.
“Football players are proud,” said David. “They do not like to be carried off the field. If they can get up, then they will walk off as best as they can. I’ve had players with dislocated shoulders, with ACL tears, even with ankle fractures, refuse to be carried off the field. Then there are some players you just can’t keep from playing. I’ve seen James Collins carry their helmets so they couldn’t go back in.
“The best story I can tell you happened in Oakland. Late in the first half, Junior Seau hurt his leg, and when I ran out onto the field, I was worried about a fractured tibia. He continued to limp and play, but during halftime, we accompanied him to a special room and took some X-rays. Afterward, I told him to wait until we could determine whether there was a fracture. We didn’t want him to hurt himself anymore.
“The X-ray developer took forever, but when I finally got a look, I could see that his tibia was negative. I ran as fast as I could to the field to tell Junior that he was okay to play, but just as I arrived, I heard the public address announcer say, `TACKLE MADE BY JUNIOR SEAU.’ That pretty much sums up Junior and all the players—they will play with pain.”
3:20 p.m.
Already, David has made four “field visits” as the first half winds down toward the two-minute warning. No major injuries; just the usual bang-ups.
Suddenly, Carl Robbins, a 70-year-old member of the chain crew, collapses like a sackful of football helmets and hits the ground with a thud. At first blush, it doesn’t look good.
Dr. Chao is first on the scene since the older man toppled within a few yards of him. Heart attack? Stroke? Dr. Chao works to clear the breathing passage and stabilize him as EMTs rush to the scene. Technically speaking, Carl Robbins is not David’s medical responsibility since the chain gang member is working for the NFL, but those technicalities are naturally brushed aside as moments like this.
An EMT places an oxygen mask on the man while they wait for a sled to arrive. Play cannot resume, however, since the chain-crew member collapsed just a few yards from the sideline. It will take 20 minutes before Robbins can be driven off in a cart and taken to nearby Kaiser Medical Center. (Later, it was learned that Robbins passed out in reaction to some blood pressure medicine he had taken. “I’ve gotten calls from Florida and Philadelphia, people who thought I was dead,” he said, adding that he was grateful for the quick medical attention.)
4:59 p.m.
We’re deep into the second half, and for the eighth time, David runs out onto the field to help an injured player. Normally, David is out on the field two or three times, but today’s game seems to be an exception. One injury looks career threatening: Charger receiver Curtis Conway’s legs twisted around like a pretzel while trying to make a catch. Instead of a fibular fracture or torn ACL, however, Conway was able to shake off the pain and even return to the game.
5:12 p.m.
Drats! The Chargers have just lost another tight game in the last minute, 13-6. Dr. Chao runs to the middle of the field for his post-game handshake with his Oakland counterparts—the Raider team doctors. Then we hustle off the field and into the locker room with the disappointed players.
Dr. Chao beckons me to follow him. Charger team chaplain Shawn Mitchell is about to lead the team in its post-game prayer. David bends one knee, bows his head, and places his hand on the shoulder of a Charger player; I do the same with Dr. Chao.
“Thank you, Lord, for Your protection today, and we ask that you help any weary and injured players on our team and on the Raiders,” says the Charger chaplain. “Please heal anyone that’s hurt, and we give You all the glory, amen.”
Dr. Chao and several doctors return to their cubbyhole office, where they will be available for the next 90 minutes or so. Sometimes after a game, it takes the players some time for the adrenaline to wear off—and that’s when the body starts sending signals to the brain that something hurts.
When that happens, they need to see a doctor who understands what they’ve been through. Fortunately for the players, they will be evaluated by an all-star team of sports medicine physicians led by Dr. Chao.

Sidebar

Up Close and Personal
Dr. David Chao
Age: 37
Marital status: single
Education background: After graduating from Beverly Hills High with honors, David attended Harvard University, where he majored in psychobiology. He then attended the Northwestern University School of Medicine (where he was a standout water polo player), served his residency at Northwestern Memorial Hospital in Chicago, and a fellowship with the Minnesota Vikings, Timberwolves and Twins.
Current team physician duties with: San Diego Chargers, Point Loma Nazarene University, United States International University, X Games (Winter and Summer), and various San Diego high schools.
Notables: He is considered a worldwide expert in hip replacement surgical techniques.
Sidebar
What Are You Doing Friday Night—or Monday Afternoon?
Dr. David Chao says that you don’t have to work in the NFL to work the sidelines. In fact, there are probably high schools in your hometown that could use your expertise during the game and afterward in the surgical bay.
In addition to taking care of the Chargers’ medical needs, Dr. Chao says doctors around the country can make it a ministry to help injured high school players without insurance or the ability to pay. “I just started my own foundation to help high school players in San Diego who need surgical care,” said Dr. Chao, who added that he probably does 20 plus free operations on injured high school football players during the year.
“A foundation can pay for the hard costs—the screws, the equipment, and hospital—so all the professional costs are free,” said David.
If you would like more information on setting up a foundation in your hometown, contact San Diego Sports Medicine Foundtation.
I hope the readers enjoyed this guest column with a small peak behind the curtain. Thanks to the author, Mike Yorkey, for allowing me to re-publish it.

Monday Morning MD: Two consecutive top-5 overall picks injured

The Jacksonville Jaguars now have the dubious distinction of having two consecutive top-5 overall picks injured early in the offseason program. Last year, Dante Fowler, Jr. tore his ACL in the first rookie minicamp practice. Now Jalen Ramsey has suffered a “small” meniscus tear.
Last week I wrote how half of teams will suffer a significant injury program. With Ramsey for the Jaguars, Shaq Lawson (shoulder) with Bills and Jumal Rolle (Achilles) of the Ravens, that makes three of the potential 16 teams already.
The size of Ramsey’s meniscus tear is not the biggest factor for a quick return. The type of tear and location (peripheral vs inner rim) determines the type of arthroscopic surgery needed: menisectomy (trimming) versus meniscus repair (sewing). A typical return from menisectomy is 4-6 weeks. A meniscus repair would mean 4-6 months out.
Statistically, there is over a 90% chance that Ramsey’s tear will not be amenable to repair, thus dictating the trimming surgery with quicker recovery. Interestingly, a previous poll of NFL players showed they would overwhelmingly choose the menisectomy (earlier return) over a repair (less long term arthritis, longer recovery) even if their tear was a candidate for repair.
Myles Jack’s knee situation with the osteochondral lesion is much different. He was another top-5 talent that fell to the Jaguars early in round 2 due to reports of needing future microfracture surgery. Jacksonville fans are understandably worried, but the two situations bear little resemblance medically.
Concern for Ramsey’s knee in Jacksonville is high as it came to light that he had a microfracture surgery as a Sophomore in high school. A report surfaced that Jaguars may contradict that he ever had that procedure. Even if Ramsey did have microfracture surgery, at age of 15, the results are much better.
I was not aware of Ramsey’s microfracture history, but I assure you the Jaguars medical staff knew the facts. For almost two decades I was in the same Combine medical room as Jacksonville and have worked with their current head athletic trainer. Yes, draftees conveniently “fib or forget” about their injury history, but team doctors know this and factor that in. Even without the operative report of the high school surgery, with portal scars on his knee, likely a MRI was obtained that would show any previous microfracture surgery. With Fowler and now Ramsey, the consecutive year injuries appear to be bad luck, not something missed by the Jaguars medical staff.
The Jacksonville GM, now knows his team doctor very well given the three knee issues of Fowler, Jack and Ramsey. If all three work out, the Jaguars could have a formidable defense and make the biggest improvement of any team in 2016. If the three knee issues do not perform well, the GM could be looking for another job.
MMMD 1: Shaq Lawson needs shoulder surgery after all
Before the draft, I indicated that the team that drafted Lawson would either do surgery immediately or hope to get through the first season with a shoulder harness and then have surgery in the offseason. Despite the player’s previous denials of any need for surgery, a labral repair surgery was performed this week. Unfortunately, the procedure means Lawson will start the year on PUP and undoubtedly miss Week 1. If rehab is smooth, Lawson could return 4-6 months after surgery, which means he could miss half of his rookie campaign.
This is not to say the Buffalo made a bad draft pick. There is no doubt the Bills medical staff was aware of the issue and the Lawson first-round selection was a calculated risk. The good news is that once healed, there should be no long-term issues.
Lawson played three years with a shoulder brace. It is not unusual that as a player steps up to a higher level of competition, injuries they could play with before, now get unmasked. Reports say Lawson re-injured the shoulder doing a bag drill. Even though it was likely that he was not wearing brace when the shoulder re-dislocated, the Bills are making the right decision to get their prized rookie fixed now.
MMMD 2: Wide receiver fracture
The Jones 5th metatarsal fracture should be renamed the WR fracture. Sammy Watkins joined a long list of recent WRs to have a screw placed in his foot. Julian Edelman, Dez Bryant, Julio Jones and DeVante Parker all had a second screw in the same foot. Others to undergo surgery for Jones fracture include Hakeeem Nicks, Michael Crabtree, Marvin Jones, Demaryius Thomas and Quinton Patton.
Other positions get the injury too: 49ers RB Carlos Hyde and teammate S Jimmy Ward among others. However, fifth metatarsal fractures are more common in wide receivers than any other position group due to the hard cuts they have to make. No one knows who Sir Robert Jones, the namesake for the Jones fracture is anymore. I propose we just call this injury a “wide receiver” fracture.
MMMD 3: Another reason for Laremy Tunsil draft tumble?
A report surfaced that Tunsil’s draft day fall may not have been exclusively related to the gas mask video. A “pre-arthritic” ankle may have contributed to the slide. Don’t forget that Tunsil had an ankle fracture/dislocation in the bowl game at the end of his junior season, but returned to play well. This injury could indeed lead to future arthritis but that typically takes decades.
College teammate Laquon Treadwell had a similar injury and was a fellow first-round pick. Then again, Darren Sproles had a similar injury and surgery early in his NFL career and is beginning his 10th season since that ankle injury.
MMMD 4: Cardinals with confidence in Tyrann Mathieu
Teams are usually hesitant about a defensive back coming off an ACL tear (see Darrelle Revis and the Jets 2012). Arizona has no such fears and is rumored to be extending the contract of the “honey badger”.
It typically takes longer for a DB to be fully effective after ACL surgery due to the demands to react to the offensive players moves. However, Mathieu already showed he could recover from a potentially career threatening ACL/LCL injury in 2013. This ACL recovery is easy compared to the last one.
MMMD 5: James Harrison’s suspicions about NFL drug test unfounded
The often-fined Steelers linebacker wondered why he wasn’t allowed to film his recent drug test. This was not a case of Harrison being singled out but it is against league policy for anyone to record the testing procedures.
Recording a test would make it easier to study the process and circumvent future testing. In a recent Olympics cheating scandal, Russia was accused of substituting clean urine samples in look-a-like bottles. Filming what the bottles look like might help in this counterfeiting process.
The NFL is often accused of acting suspiciously (see Deflategate), but this does not seem to be the case here.
MMMD 6: Crazy stories
We have gotten numb to off field stories from Aaron Hernandez to Johnny Manziel. Add two more unbelievable stories that involve two players I know, respect and wish the best for. Erik Kramer survived a suicide attempt where he shot himself in the head. Reche Caldwell landed in jail after casually ordering drugs over the internet.
There are many positive stories about former players, we just don’t hear about them as often. This weekend was the Marshall Faulk Celebrity Championship that has raised hundreds of thousands of dollars for charity. What is unique is that Faulk primarily raises money not for his own charity, but for the Junior Seau Foundation. After the 2012 death, the NFL MVP of 2000 voluntarily stepped up to take the lead to continue to raise money in Junior’s absence. Faulk just wants to pay Seau back for his encouragement when the young running back starred at San Diego State.
I would rather hear more about these great charitable acts from players than hear more crazy stories about former players.
MMMD 7: ProFootballDoc Scorecard
The 2016 record was 5-0 even though injury predictions/assessments are sparse this time of year.
Prior to the draft, I indicated Shaq Lawson would need shoulder surgery, which he denied even after the draft. With his recent labral repair, that increases this seasons total to 6-0.

Monday Morning MD: #1 priority of minicamps

‘Tis the season for rookie and team minicamps. The intent is to indoctrinate rookies, provide a primer on new terminology and get an early talent evaluation. However, teams have an underlying more important goal.
Everyone’s main objective is to finish minicamps injury free. In my 17 years as a NFL team physician, it seemed that every other year my team suffered a significant season altering injury to one of our main contributors. Lead pass rusher Melvin Ingram tore his ACL in the 2013 Chargers mini-camp. Last season, Jaguars #3 overall pick Dante Fowler Jr. ruptured his ACL on the first day of minicamp and missed his entire rookie season. The Broncos suffered the same fate last year with tight end Jeff Heuerman.
Clubs have a focus on trying to stay healthy. After last year’s loss, Jacksonville has made it a bigger priority to stay injury free and have changed their rookie minicamp.
Statistically, over 50% of teams will have a season-ending injury during offseason activities. Last week, Ravens cornerback Jumal Rolle tore his Achilles tendon and will miss 2016.
The most common offseason injuries are muscles strains including the hamstring, groin, quad and calf, which usually recover in plenty of time. ACL and Achilles tears are the feared ones that will lead to a loss of the upcoming season. These injuries are commonly high-speed non-contact injuries. Thus, even with limited contact practices, the new CBA has not resulted in lower numbers of these injuries. Achilles have become the new ACL with increased numbers and both are dreaded season-enders.
The main priority has become staying healthy while accomplishing offseason goals.
MMMD 1: Julian Edelman with a second foot surgery
Early reports called the procedure minor and that he would be back for training camp. Edelman had revision surgery where a screw was reinserted into the same left fifth metatarsal bone. Also called a Jones fracture, this is a problem fracture due to its poor blood supply. Returning to play early increases the chance of needing a second procedure, which often is accompanied by bone graft.
Needing a second surgery for a Jones fracture is not unusual and does not indicate mismanagement by the surgeon or Patriots medical staff. When hurrying back to play, this happens up to 20% of the time. Recent examples of needing redo surgery include Dez Bryant, Julio Jones and the NBA’s Kevin Durant.
Healing after revision surgery typically takes 3-4 months. It is possible that Edelman will be ready for the start of training camp but is it more likely he begins on PUP and targets a return before the first real game. If the Patriots are unlucky, it is possible they could play early season meaningful games without Tom Brady and their #1 wide receiver.
MMMD 2: Dez Bryant recovery from second Jones fracture surgery
The Cowboys wide receiver returned six weeks from his initial fifth metatarsal screw placement but never really excelled, posting a maximum of five catches in a game and totaling three touchdowns in 2015. After revision surgery, he is reported to be recovering well and on target to participate in some of OTAs and the June minicamp.
The key here is Bryant had his 2nd foot surgery in January and “isn’t fully cleared yet”.  If Julian Edelman follows this timetable, his May surgery will have him back in October. The take home message is to be careful with fifth metatarsal fractures.
MMMD 3: Melvin Gordon microfracture surgery
When the word “microfracture” is used, many jump to the conclusion that a player is doomed. I agree with Chargers GM Tom Telesco. Not all microfracture surgery is the same and the key is the size and location of the lost articular cartilage.
I have not treated Gordon and do not know the circumstances of his surgery, but given the optimistic return guideline of 4-6 months and the reports of his workout progress, the running back should be on course for a much better 2016 than rookie year. The team knows the details of the January surgery, yet they did not draft a running back or add one in free agency. That likely speaks loudly to the Chargers’ confidence in their starting running back’s rebound for a strong year.
MMMD 4: BFR and Le’Veon Bell
The Steelers RB is among the latest new believers of blood flow restriction (BFR) training. I have written about this new game-changing rehabilitation technique.
The question is will BFR be enough to get Bell back for next season. The Steelers have set no timeline. In general, MCL/PCL surgery is harder to recover from than an isolated ACL tear. Simply put, recovering from two torn ligaments is harder than returning from one. There is no guarantee that Bell will be 100% or even ready to play Week 1, but if he is, BFR will share in the credit for his return.
MMMD 5: Ricardo Lockette didn’t have a choice
Big news of the week was the Seahawks WR/ST retiring from football. Congrats to Lockette on his decision to walk away healthy.
The reality is that the injury and subsequent surgery caused him to lose significant rotation in his neck motion. A spine fusion from C1-C4 leaves him with well under 50% of his ability to turn his head to the right and left. It would be unprecedented to return to football from a three-level fusion.
Lockette made the right choice to retire, but the medical reality is that he didn’t really have a choice.
MMMD 6: Kudos to NFL player engagement
I personally know of dozens of players who have taken advantage of programs. From broadcast boot camp, finance workshops to coaching or scouting internships, there are many programs aimed at giving former players direction. I am not saying the NFL is perfect in all aspects related to former players but I see an honest effort to help players with life after football careers.
MMMD 7: ProFootballDoc scorecard
In the offseason, I have not updated the running 2016 scorecard each week as activity is sparse. I will still keep tabs this season and see if it is possible to continue the slight improvement from 92.6% in 2014 to the 94.3% in 2015.
In early March, the Byron Maxwell and Kiko Alonso trade to the Dolphins was rumored to be off due to Maxwell’s physical, which noted sternoclavicular (SC) joint problems. I tweeted at the time it was likely the deal would still go through and it did. Despite worry about Tony Romo’s offseason surgery to decrease the chance of recurrent clavicle fracture, I correctly indicated that the Dallas QB would be fine and indeed he is already cleared and throwing 100%. Prior to Jaylon Smith’s Combine medical evaluation, he was universally thought to be a top pick. Seeing video posted by the player, I concluded nerve issues and indicated that unfortunately he would fall out of the first-round.  I even got lucky and predicted the Cowboys would draft him. Myles Jack is able to play football today, but an OCD lesion would drop him out of being a top 10 pick.
Adding these four correct assessments to the 1-0 2016 record leaves us with a 5-0 start for this coming season.